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WELL ERMIT APPLICATION Fb�M <br /> SITE <br /> ,;SAN JOAQUIN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., .95202 <br /> „ (209) 468-3449 \/V D ' <br /> �• l <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED <br /> Application is hereby made'to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San , <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin Co „ty Environmental Hea Department. <br /> WELL Location / r W Cross Street �/t S C� S2 Parcel#Assessor's JD J_Ic/�Zj <br /> �E r _ 5 r <br /> 7 <br /> PROPERTY Owner Pi ddressp Cu 77 p City 1 Zi Phone# <br /> C-57 Contractor �f la dress C7 ��� City+v. �!S'�'�- Z1pi`f6 flLici 11)MPhone#2 W7 43� <br /> Consultant I Sub Contractor-4*101C_ Address Phone# �ilO7f <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> 0 NEW WELL BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) r$6ESTRUCT e e e aw <br /> d SOIL BORING# <br /> JI-WELL# !'Mil l 'IrOVER-80 <br /> ESSURE GROUT <br /> 'Other: Grout'Specifications: I <br /> COMMENTS: <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS,. <br /> XMONITORING 4H0LLOW STEM DIA.OF BOREHOLE MU TIPLE CASINGS?[]YES (]NO WELL CASING bIA: <br /> Q RACTION <br /> Q AIR HAMMERIDRIVEN C�.SW TYPE OF CASING_ a STEEL ]]PVC a OTHER: <br /> 11 VAPOR n MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: n AUGERS [I HOSE t <br /> []AIR SPARGE PUSH_P_OtiVX�. ,w GRP—SEAL.PUMP_ED:-_[],,Yes-�-U-NoINOTE ' IMUMJ FREE=F_ALL DEPT]4-T 30}} ____1 <br /> Y mow— <br /> o SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: <br /> i. <br /> 0 OTHER: OTHER APPROX.BORING DEPTH []BOLTED TRAFFIC BOX or {]STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> .'COMMENTS: Iwl�k111 ��Ji�-f7�(f�,tL�i-1 <br /> NOTE: OFFSITE BORINGS'REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> p <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin. <br /> County Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x / Title/companyZOL <br /> Print Name ? 1 �� Date 4 C <br /> DEPARTMENT USE ONLY $ <br /> -SITE MAP IN UNIT IV FILE,ADDRESS: 117 aD-3 <br /> WORK PLAN DATED: 9 S 0 2-- <br /> Application <br /> /Application Accepted By '! Date Issued a �r y <br /> Grout Inspection By Date b Z Final Inspection By ate <br /> Destruction Inspection By Date <br /> _ a <br /> COMMENTS 1 CONDITION$: "noll <br /> . t <br /> ACCOUNTING ONLY: AID# <br /> rarer <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# `r RECD BY . DATE PERMrr/SERVICE REQUEST# INVOICE <br /> 3502- (¢o l© 9a 1-L7q SR# 3/.Z6 Z <br /> C-57 WC -WAIVER C-57 Letter of Authorization to sign permit Encroachment doc- 1/25/02 `� <br />